•
Sub-specialisation related to clinical fields and continuous participation in
multidisciplinary activities in the hospital are key factors contributing to
the radiologist’s clinical relevance to patients and colleagues.

•
Implementation of the evolving hybrid imaging modalities requiring knowledge
and skills in both radiology and nuclear medicine can best be accomplished when
both disciplines are integrated in a central imaging department.

The close relationship
between the evolution of information technology and advanced biomedical
engineering leads to a constant, strong innovative drive for radiologic
imaging. Modern advanced imaging offers unprecedented medical information.
Cross-sectional imaging techniques, especially magnetic resonance imaging (MRI)
and computed tomography (CT) are generally considered to be among the most
important innovations in modern medicine (Fuchs and Sox 2001), and have a
central role for patient care in every major hospital. Due to the increasing
role and unique opportunities of these powerful technologies, and the high cost
related to imaging equipment for the hospital, the question may be raised:
which is the optimal organisational form for implementation of these powerful
technologies, and what is required in terms of knowledge and skills in order to
serve the patient best?

The Central Radiology Department: Opportunities

The optimal form of the
radiology department depends on a variety of factors, including architectural layout
of the hospital, available space for imaging equipment, logistics for
inpatients and outpatients and distribution of medical specialties within the
campus. A central hospital imaging platform organised in the form of an
integrated radiology department, including all biomedical imaging services
offers many synergistic effects (Krestin 2009). These include long-term
planning and investment strategy for heavy equipment, medical, technical and administrative
staff, IT systems such as Radiological Information Systems (RIS) and Picture
Archiving and Communication Systems (PACS) for the entire service chain from
scheduling to reporting, risk management, quality management, logistics and
ergonomics.

Providing 24/7 coverage for diagnostic
and interventional radiology in a large general hospital or tertiary referral
centre hospital requires a large team of radiologists trained in several
sub-specialised areas, such as interventional radiology, neuroradiology or paediatric
radiology, but also sufficient “all-round capabilities”. This is more easily
provided by a large central imaging department than by small delocalised and
sub-specialised medical units.

Using imaging equipment for
all indications and all patients of an institution may allow optimisation of
processes for patient care, cost-effective use of resources, and of fer
adequate training for medical, technical and administrative personnel. Most
biomedical imaging procedures require risk management related to safety
aspects of ionising radiation, contrast agents, magnetic fields, intravascular
procedures, etc. The quality processes, which are needed in order to guarantee safe
imaging to the patients, are best implemented in a common management structure.

Postgraduate training
programmes and acquisition of expertise in subspecialised fields of radiology are
easier to plan and implement in unified imaging departments with access to all
modalities and subspecialties than in decentralised structures, in which
imaging is integrated into different clinical departments and postgraduate training
programmes.

Finally, professionals
providing expertise in areas that support the activities of the radiologist such
as MR physics, informatics, image processing or quality management can usually
only be afforded by larger structures where they can create synergistic
effects.

Challenges: Performance Criteria

The performance of a modern
radiology department can be measured by a variety of criteria:

• The patient wishes for
timely and personalised scheduling, a “smooth and safe” experience in the
department and access to information whenever needed.

• Residents look for a
complete, didactic postgraduate training programme and interesting career
plans; their satisfaction may be surveyed by central authorities.

• Hospital administrators
tend to look mainly at indicators for process efficiency or for quality, such
as patient satisfaction, team management and return on investment.

• Academic departments are
in addition measured by their contribution to undergraduate training, their third-party
research funds and scientific output, and the academic
careers and visibility of their staff on a national and international level.

A
successful radiology department should meet all of the above performance criteria
- a challenge for leadership.

Challenges and
Opportunities: Digitisation and “Commoditisation”

Because
PACS are now widely used in hospitals, images acquired in the radiology
department can be immediately made available to the referring physician for
visualisation. The traditional flow of information in the hospital has,
therefore, become considerably accelerated, and referring physicians may be
tempted to self-interpret images that are not accompanied by a radiology report
immediately, albeit a preliminary interpretation. Decentralised or even remote
post-processing of standard diagnostic images is possible in many institutions
by means of web-based or dedicated post-processing software. Specialised
clinicians may make use of these tools for various purposes, such as treatment
planning, quantitative image evaluation, or scientific or didactic
applications, without involving the radiology department.

The
term commoditisation refers to imaging being regarded as a relatively undifferentiated
technical service that can be offered anywhere, in a competitive fashion, thus
undervaluing the expertise of the radiologist for imaging protocol management and
interpretation (Forman et al. 2011). Certain referring physicians may even
choose to self interpret or re-interpret imaging studies.

Image
communication outside the hospital opens up a variety of opportunities for the
radiology department. These include the creation of intraand inter-institutional
networks, improved availability of previous imaging studies, expert
consultation for difficult imaging studies or second opinion services. On the
other hand, teleradiology services also offer the possibility to economise on
local radiology staff by sending locally produced images to distant radiology
services for interpretation.

Challenges:
Increasing Medical Sub-specialisation

The
trend towards sub-specialisation in internal medicine and surgery related to
organ or disease entities often provides the referrer with increased knowledge
with regard to the indications for imaging, radiologic anatomy and expected
pathologic findings. Radiologists working in multidisciplinary teams or
diseaserelated “centres” thus require additional knowledge in the fields of
their clinical counterparts and in-depth knowledge of their needs.

Some
imaging procedures and image-guided interventions are the object of “turf wars”
between nonradiologist physicians such as cardiologists, neurologists or
vascular specialists. Several reasons may explain the interest of
nonradiologists physicians in “owning” an imaging procedure: (1) the knowledge acquired
in a given field may make the nonradiologist physician believe that he or she
can or must do without a radiologist, especially in situations where the
radiology department does not or cannot provide trained and skilled staff
radiologists in the respective field; (2) ownership of an advanced imaging
technology may appear to a sub-specialised non-radiologist physician as an
advantage to his or her field as a research tool and for promoting careers; (3)
self-referral offers the opportunity to confirm the physician’s own diagnosis,
and also gives financial incentives, although it has been shown that the
practice of self–referral results in overuse of imaging procedure and increased
cost for the health system as compared with radiologist referral (Hillman et
al. 1990). Self-referral requires direct access to imaging technology. Although
this may be easily obtained in the case of ultrasonography, different forms may
apply in the case of CT, MRI or nuclear medicine. Nonradiologists may obtain imaging
privileges for certain indications on certain equipment of the radiology
department, with the radiology technician reporting directly to the clinician,
or both imaging equipment and technical staff may be integrated in nonradiology
departments, thus leading to decentralisation of imaging services. Whatever solution
is preferred, the radiologist will always end up in an unfavourable position if
his referrer chooses to become a competitor for a given procedure.

Radiology
departments providing adequate subspecialised imaging services in the relevant
clinical fields of the hospital are much less at risk of being involved in “turf
wars” as described above than departments who are staffed by general
radiologists. The concept of radiologic subspecialisation must correspond to
the local referral patterns, workload and needs in a hospital with regard to
clinical fields that may be organ-related, patient-related or pathology-related.
At least 2-3 radiologists with subspecialty training are usually required for
full coverage of a relevant field with regard to clinical services, teaching
and research. This number increases to 4-5 for subspecialty areas where 24 hour
services are to be provided, e.g., for interventional radiology. Depending on
the local situation, a matrix system may often appear useful, in which some staff
radiologists may be integrated in more than one subspecialty.

Fellowship
training positions can be established in relevant subspecialties; advanced
training usually requires a minimum of two years, depending on the local
spectrum. This concept provides interesting career opportunities for senior radiologists,
provided that sufficient staff positions are available in the radiology department, and organisation in the form of subspecialty units can be created. The
structural and financial requirements may represent a leadership challenge,
because the hospital administration needs to be convinced to invest in the
central radiology department, and rely on its organisational structure.

Clinical
Relevance of the Radiologist

In
order to make radiologic medical expertise valuable in the modern multidisciplinary
environment, radiologic services need to be fast, accurate, accessible and
relevant (Forman 2011). This includes competent guidance with regard to imaging
indications, adequate risk management and protocol selection for individual
imaging studies, quality and timeliness of repor ting, active participation in
the definition of clinical pathways, availability for second opinions on
external images (role of consultant) and regular par ticipation in
subspecialised clinical rounds and tumour boards. The subspecialised
radiologist remains attached to his or her depar tment, but works closely with
his clinical counterpar ts, and ensures advanced postgraduate training and
research activities in his field. He or she may also have a key role
representing radiology in disease–related multidisciplinary centres (Reekers
2014). This form of organisation places the patient in the centre of the
multidisciplinary team of specialists (see Figure 1). It has been shown in
tertiary cancer care centres that radiologic consulting leads to important
changes in patient management. However, the average daily work volume for
second opinions and reinterpretation of external images may add up to almost
20% of the workload of a senior radiologist (Brook et al. 2011; DiPiro et al.
2002).

Role of
Nuclear Medicine

Although
the role of traditional scintigraphy has diminished significantly over the past
decade, new imaging modalities combining MR and CT with modalities such as
positron emission tomography (PET) or single – photon emission computed
tomography (SPECT) have been successfully introduced in clinical medicine. Because
the implementation and interpretation of PET-CT, MR-PET and SPECT-CT requires
technical and medical skills related to both radiology and nuclear medicine, these
combined imaging modalities are also referred to as “hybrid imaging techniques”,
and play an increasing role in clinical fields such as oncologic imaging,
neuroimaging or musculoskeletal imaging. Hybrid imaging may also have an
increasing role in the future with regard to new molecular imaging techniques
in the context of “personalised medicine”and “theranostics” (European Society
of Radiology 2011).

It appears obvious that the organisational structure of a modern imaging
department should allow for training curricula that enable some trainees of
these disciplines to acquire certification in both disciplines, so that subspecialists
eventually can interpret all relevant imaging modalities that are relevant in
their respective fields. Clearly, this can be best achieved in structures where
nuclear medicine is integrated with radiology in the same department. Although
this is the case in many North American institutions, organisational structures
in Europe are currently still quite variable, as are the training programmes
for dual specialists in many European countries. However, change is likely to
occur over the years to come.